General Health Benefit Information

Frequently Asked Health Benefit Questions

When may I enroll in the college’s health plans or make changes?

An employee is eligible to enroll within 30 days from their hire date. After that you may enroll or make change every year during the open enrollment which takes place in October for a November 1st effective date. You may always make changes when a qualifying event occurs such as marriage, divorce, birth, adoption or death of a dependent, but these additions or deletions must be made within 30 days of the date of the event. So, should you have a baby, please make sure you notify Human Resources to add the baby within 30 days of his/her birth otherwise the baby will not be covered.

Will I receive enrollment cards?

Both Health Net (medical) and Aetna (dental) issue enrollment cards. VSP, the vision plan does not.

If I move, whom should I contact to change my address?

You should remember to change your address with Health Net and/or Aetna, depending on which plans you are enrolled in. You should either call the customer service number listed on the back of your enrollment card or call this office and a written change will be mailed. No change is necessary for the vision plan.

May I terminate the medical, dental or vision coverage any time I wish?

Yes, but you will not be able to re-enroll in the medical or dental until the next open enrollment period or unless you lose coverage elsewhere and can supply proof of such. If you cancel your coverage in the vision plan you will never be able to re-enroll unless you can supply proof of having lost vision coverage with another carrier.

May I switch from the Dental DMO Plan to the PPO Plan or vice versa?

Yes. If you are enrolled in the DMO and are dissatisfied with the in-network dentists, you may switch to the PPO where you may go to any dentist of your choice. Remember that the benefits are not as rich in the PPO and that there is an annual maximum paid of $1,500 per calendar year per enrolled member. You should call Aetna Customer Service (877-238-6200) directly to effect the change. If you request the change during the first 15 days of a month, the change becomes effective the first of the following month. If you request the change the last 15 days of the month, the change is effective not the first of the following month but the first of the month thereafter.

How do I use the vision plan?

Call an in-network provider and make an appointment, giving your social security number so the provider can confirm your eligibility. When you go for your appointment, if you do not like the selection of frames available to members, you are allowed $90 off the retail price of any frame in the store. If you go to an out-of-network provider, submit your claim as instructed in the VSP benefit summary. You have six months in which to file. Benefit summaries and directories of participating providers are available in the H.R. office.

My dependent child is 19 years old. May he/she remain on my SLC health policies?

Effective December 31st of the year in which your child reaches age 19, he/she will automatically be dropped by the health insurance carriers, Health Net (medical) and Aetna (dental) unless enrolled as a full time student. With full time student status, he/she may remain on the health plans until the end of the calendar year in which he/she graduates or reaches the maximum age allowed by the plan, whichever comes first. For the medical plan age 24 is the maximum and for the dental plan age 25 is the maximum.It is the parent’s responsibility to verify student status and if this is not done annually, the insurance carrier will drop coverage on your child. For Health Net file a student verification form which is available in the H.R. office, on the College’s web site or by calling Health Net. For Aetna, send or fax either a tuition bill or course schedule that indicates a full time status. You can call the customer service numbers on the back of your enrollment cards for instructions on where to send or fax this information.

Please remember, this is the parent’s responsibility.

What is the advantage of using the mail order prescription drug program and what is the procedure?

If you or your dependents are on maintenance drugs you can save on co-pays by using Health Net’s mail order prescription service. You may purchase a three-month supply for the price of two co-pays. Yearly savings range from $20 for a $5 co-pay drug to $120 for a $30 co-pay drug. Ask your doctor for a one-year prescription and send it with a completed Express Scripts order form. Forms are available in the Human Resources Office or from the Health Net Website. A written prescription is necessary for the initial three-month supply. Subsequent refills, each for three months, may be requested by phone or by Internet.

Does Health Net (medical plan) cover any dental services?

Yes, medical injury to the mouth is covered by the Health Net medical plan. Additionally, a New York State mandatory rider provides oral surgery benefits for complicated impacted tooth extractions. This would include the extraction of complicated impacted third molars or wisdom teeth. Call Human Resources or see you full plan summary for using this benefit in-network or out-of-network.

Mental Health Benefits

In an effort to receive the maximum benefit allowed under our policy, I wanted to review the benefit, both in-network and out-of-network, and the out-of-network claim filing procedure. Getting mental health claims paid are a source of frustration and I am happy to help you personally. By being better informed, it will be easier for you to determine if your claim has been processed incorrectly and if you need my assistance. Both the HMO and the POS policies have a rider extending the number of visits per calendar year from 20 to 30, when deemed to be medically necessary.

  • In-network Benefit: This benefit is managed by MHN, meaning that you must have prior authorization after the 6th visit to continue seeing your therapist (provider) for the 7th through the 20th visits. For the 21st through the 30th visit, your provider must prove to MHN that it is medically necessary for you to continue with treatment. Your co-payment is $15 per visit and there is no claim to file. Your provider will do it.
  • Out-of-network Benefit: This benefit is NOT managed and you do not need prior authorization is needed in order to utilized the allowed 30 visits. As the rider states, the additional 10 visits are suppose to be medically necessary but I have consistently seen MHN cover 30 visits per calendar year. Most errors in processing claims, falls into the category of “failure to prior authorize” and members are incorrectly penalized. Even those members who are aware of this cannot make the MHN customer service representatives understand that if they diligently read to the end of our policy they will find this provision. If this happens to you, please get the representative’s name and date of the call. Pass it on to me along with copies of your claim and I will have it corrected through the New York regional office.

Filing an Out-of-Network Mental Health Claim:

MHN now has a strict policy on how claims are filed. They must be filed on a HCFA form which will be electronically scanned. For this reason, MHN will not accept bills on provider's letterhead since they must be manually entered. Some providers use the HCFA for billing. I have copies in the Human Resources office, or you can access it from MHN's web site at www.mhn.com. Click on "Members", "Member Information & Forms" and under "Out-of-Network Claims" you will find a link to the HCFA form. You will need Acrobat Reader to download the form and instructions for filing. You can list 6 dates of service on each form. Fill out each section completely (do not write "Same" where duplicate information is requested-a computer is reading the form). Have your provider enter the diagnosis and CPT codes, tax ID number, name, address and sign. Keep copies for your records, then mail to the Kentucky address printed in the upper right hand corner along with the Out-of-Network claim form for mental health. Expect 6 to 8 weeks for processing of claims.

Medical Hints and Reminders

Denied or partially paid claims may result from a member not knowing or not following Health Net’s policy as outlined in the subscriber contract. Since the goal is for you, the member, to obtain the maximum benefit allowed, these are some tips based on recent experience.

For HMO members or POS members using in network providers:

  • If you receive a bill for services that you thought were covered, call Health Net Customer Service at 1-800-441-5741. Health Net has informed us that claims are more favorably reviewed when the member makes an effort and calls first (not SLC). This is the same phone number that is listed on the back of your ID card. Note the name of the Customer Service Representative that you speak with and the date. Explain the problem to the Rep and make sure it is documented in your record. If Health Net is going to initiate action on the claim, call back in a few days to confirm that the notes were entered and ask what has been done. If the Rep advises you to initiate action, make sure you follow through on a timely basis. Do not assume that the bill will resolve itself.
  • If an in network doctor uses an out-of-network provider (such as a lab other than Quest), call Customer Service and explain the problem. They need to resolve it from their side.
  • If you are certain that the doctor you are seeing is in network, pay only the co-pay you feel you owe. Do not pay the doctor’s full fee. It is very difficult to get reimbursement after the fact.
  • If you are dissatisfied with the results of your efforts, then call Human Resources (x2364) and provide me with all the bills, explanation of benefits from Health Net and any other supporting documentation.

POS members using out-of-network providers:

  • It is YOUR responsibility as the member to begin the prior authorization process for any and all procedures that may require it. Customer service can tell you which procedures need it. You or your doctor must call and complete the process five (5) days in advance of the procedure otherwise you may risk losing a substantial part of your reimbursement.
  • When filing an out-of-network claim, please remember that you have only six (6) months from the date of service. If you fail to file within that time frame it will be rejected due to having exceeded the filing limitation.

All members:

  • If, for any reason, you question the advice being give by Customer Service, ask to speak with a supervisor. It is within your rights to ask; supervisors are more experienced.
  • If you have questions regarding coverage, please call Customer Service or Human Resources (x2364). Your doctor’s office staff may be willing to help but it is impossible for them to know the details of Sarah Lawrence’s policy.

If you have questions about any of the insurance plans, need forms or experience any difficulty in making a claim, contact Lois Booth Associate Director of Human Resources by email, or call her office at 914-395-2364.